West Coast Global Insurance - Mexico Home Insurance Online Application | Mexican Home Insurance Online Application
Contact: Jason Wagner
Info@MexicoInsuranceExperts.com
office: 818-788-5353
www.MexicoInsuranceExperts.com
IMPORTANT NOTICE: This insurance will only apply in Mexico under the Mexican Legal System. No Coverage is afforded in neither the United States or Canada's legal system.
First Name
Last Name
DATE OF BIRTH ,
OCCUPATION
ADDRESS IN USA or CANADA
CITY
STATE
POSTAL CODE
TELEPHONE IN USA
TELEPHONE IN MEXICO
FAX
EMAIL
2ND EMAIL
How did you hear about Us or Find Us??
DETAILS ABOUT THE INSURED LOCATION
DWELLING TYPE: REQUESTED EFFECTIVE DATE              12:01 AM
MEXICO PHYSICAL ADDRESS (Include Lot &/or Unit #):
CITY :   MUNICIPLAITY :  
STATE :   MEXICO POSTAL CODE :  
MAIN STRUCTURE SQ. FT.(Air Conditioned Space): Sq. Ft. OTHER STRUCTURES DETACHED SQ.FT: Any Detached Structures such as Casitas, Detached Garage, Pool, Surrounding Walls, Pools, etc.:

 Sq. Ft.
LOT AREA Total Sq. Feet :

  Sq. Feet
ORIGINAL YEAR BUILT: HOW MANY YEARS OWNED:  

# OF STORIES/LEVELS within HOME or CONDO :

 
ENTER YEAR OF LAST UPDATE or REMODEL
ROOF HEATING / AC
PLUMBING INTERIOR
WIRING EXTERIOR
CURRENT or RECENT INSURANCE
INSURANCE COMPANY ANNUAL PREMIUM $
POLICY NUMBER EVER CANCELED
EXPIRATION DATE   EVER NON RENEWED
REQUESTED COVERAGES AND LIMITS OF LIABILITY
Section

Coverages

Check Coverage Type and Enter Values as applicable

MINIMUM DEDUCTIBLES

(Check Requested Items below)
Homeowners Condominium
Homeowners Condominium
Apartment
Per Loss/Event
Property Coverages
A: Dwelling Value
Replacement Cost
Enter Limit: $ USD
NOT COVERED
Theft:
B: Other Structures
Up to 10% of Coverage A
Enter Limit: $ USD
NOT COVERED
All Other Perils:
$500.-
C: Personal Property-Repl. Cost
10% to 50% of Coverage A
Enter Limit: $ USD Enter Limit: $ USD
Loss of Use:
3 Days Waiting Period
D1: Additional Living Expense
Up to 20% of A or 40% of C
Enter Limit: $ USD Enter Limit: $ USD
D2: Loss of Rents –Annual Rental
Up to 20% of A or 40% of C
Enter Limit: $ USD Enter Limit: $ USD
Loss of Rents: $1,000.-
Debris Removal
Up to 10% of A or 20% of C
Enter Limit: $ USD Enter Limit: $ USD

Liability
NO DEDUCTIBLES for Section II
E: Personal Liability in Mexico

Limit Per Occurence


Check Selected Limit
$300,000
$100,000
$500,000
$250,000
$1,000,000
$500,000
F: Medical Payments in Mexico
INCLUDED
INCLUDED

Catastrophic Losses
G: Earthquake & Volcanic Eruption  
Yes No
of Combined Limit, PLUS
20% of each Loss
H-I-J: Hurricane, Windstorm & Hailstorm, Flood, Tidal Waves
Yes No

Scheduled
Valuables
K–N: Jewelry, Silverware, Art & Other Valuable Property per attached schedule
Yes No Enter Total: $
Per Schedule

Do you have any Solar Panel or related equipment to be covered?

ADDITIONAL INTERESTS: MORTGAGEE (MG) AND/OR ADDITIONAL INSUREDS (AI)/INTERESES PREFERENTES         Yes No
IMPORTANT INFORMATION ABOUT THIS INSURANCE
WHEN AN INSURANCE POLICY IS ISSUED, IT WILL BE BASED ON THE INFORMATION PROVIDED ON THIS APPLICATION. UNDER MEXICAN LAW, ANY MATERIAL MISREPRESENTATION OR CONCEALMENT WILL INVALIDATE THE INSURANCE. PLEASE BE ACCURATE.
UNDERWRITING INFORMATION – SELECT MOST APPROPRIATE BOX – ALL 15 ITEMS MUST BE COMPLETED
 
1. Structure Walls
ONLY Masonry, Cement, Brick, Concrete or Steel Predominantly Masonry, Cement, Brick, Concrete Predominantly Frame Stucco Predominantly Wood or other combustible material
1A. Structure Walls
2. Interior Walls & Ceilings
ONLY Masonry, Cement, Brick or Concrete. Mostly Masonry, Cement, Brick or Concrete; with some wood, Frame Stucco or Plaster Predominantly Frame Stucco or Plaster Predominantly Wood or other similar combustible material
3. Roof
Non Combustible: made of Masonry, Cement, Concrete, metal or Tile Fire Resistive Shake, Composition or any other guaranteed similar material. Other types, including Wood Shake, but NOT PALAPA type materials Other types, including Wood Shake, but NOT PALAPA type materials
3A. Roof Type
4. Detached Structures
NONE, or made ONLY of Masonry, Cement, Brick, Concrete or Metal walls and non combustible roof Predominantly made of Masonry, Cement, Brick, Concrete or Metal walls and fire resistive roof. Predominantly Frame Stucco or Plaster walls with NO PALAPA roof or materials. Any Structure with a PALAPA roof or similar type of highly combustible materials.
4A. Detached Structures
5. Property Type
Home, Condominium or Apartment within a Gated Building or Community Home, Condominium or Apartment within City Limits or within a Beach Resort Home, Condominium or Apartment no more than 10 Miles outside of City Limits Property located more than 10 Miles away from the closest City
6. Owner Use and Rental Only Used by Owners & Guests. NOT Rented to Others Mostly used by Owners/Guests. Not Rented over 30 days per year Used by Owners, but rented to others 31 to 180 days per year Rented to Others for more than 180 days during the Year
7. Occupancy Vacancy Occupied at least 9 months during the year and never vacant for 30 consecutive days Occupied at least 6 months during the year and never vacant for 60 consecutive days Occupied at least 3 months during the year and never vacant for 90 consecutive days Occupied less than 3 months during the year or vacant for 90 or more consecutive days
8. Fire Detection Permanently Monitored Central or Police Station Fire Alarm System. Fire detection System with Smoke Detectors connected to Audible alarm No automatic Fire Alarm, but Smoke Detectors and Fire Extinguishers No Fire Alarm and/or No Smoke Detectors or No Fire Extinguishers
9. Security Permanently Monitored Security Alarm or 24 hour Security Guard Service Caretakers permanently living on premises or daily Security Patrol Service Audible Security Alarm or formal periodic (at least weekly) patrol service. No Security Alarm or formal Security Service.
9A. Security Does your Home or Condo have Bars on the Windows? Yes No
9B . Security Is the Home or Condo Located in a Gated Community? Yes No
9C . Security Does your Home or Condo have a Central Alarm System either Local or Monitored Yes No
10. Exterior
& Safe Protection
Double Dead Bolt Locks for doors AND Bars for all windows AND bolted Security Safe Two of Either: Double Dead Bolt Locks Doors, OR Bars on all Windows, OR Bolted Security Safe One of Either: Double Dead Bolt Locks Doors, OR Bars on all Windows, OR Bolted Security Safe No Double Dead Bolt Locks and No Bars on all Exterior Windows and Doors; and/or No Safe
11. Fire Department Fire Department located within 1 Mile From property Fire Department located between 1 and 5 Miles From Property Fire Department located over 5 but under 10 Miles From Property Closest Fire Department is more than 10 Miles Away
12. Water Supply Readily available own additional water supply with pumping capability Nearby private or public water supply with pumping capability Public or private water supply, but no pumping capability No additional water supply and no pumping capability
13. Swimming Pool/SPA NONE; or fully fenced pool or spa, refurbished in last 5 years with no slides or spring boards Fully fenced Pools and/or spas over 5 years old with no slides and no spring boards Pool-spa refurbished in past 5 years, but is either not fenced, has slide or spring board Pool or Spas older than 5 years that are either not fenced or have slides or spring boards
14. Flood & Tidal Water Location is at least 10 miles away from any ocean waters, river beds,lakes or dams Location is between 1 and 10 miles away from any ocean waters, river beds,lakes or dams Location within 1 Mile from any such waters bodies but AT LEAST 300 Feet Above Water LEVEL Location within 1 Mile from any such waters bodies but LESS THAN 300 Feet Above Water LEVEL
14A. Distance from Body of Water In the Drop Down select the closest answer to the distance your property is located away from any body of water?
15. Weather Permanent or Professionaly made ready to install Storm Shutters for all windows & exterior openings Wood Panels pre-made by owner and readily available to cover all windows and exterior openings No Storm Shutters or storm protection available at this time, but will install if required by policy No Storm Shutters or storm protection is available and will not be installed
SUPPORTING
DOCUMENTS
VALUABLE PROPERTY SCHEDULE
Required for Section IV Coverages
SELF-INSPECTION
REPORT
Required for Homes over $500,000
PHOTOGRAPHIC
REPORT
Required for Homes over $500,000
OTHER (Describe)
UNDERWRITING QUESTIONNAIRE

1. Do you have any Autos in Mexico?

Yes  No

2. Do you currently have auto insurance in Mexico?

Yes  No

3. How much time of the year are you traveling out of your Home country?

4. Are your Trip Durations out of your Home Country More or less then 30 days at one time?

NOTES: Limitations & or no coverage is applied to those homes that have exposures such as (Palapa or Thath Roofs). We do have markets for these exposures but it is important that we are aware of this prior to submitting your application to Underwriting.
LOSS HISTORY – LIST ALL KNOWN LOSSES OVER THE PAST 5 YEARS (If NO LOSSES write NONE below)   Yes   No
DATE
DESCRIPTION
INSURANCE COMPANY
POLICY NUMBER
AMOUNT PAID

Space for Additional Information, Comments or Notes:

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